B-2016-3307 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3307
6 INFINITE LOOP CUPERTINO,CA 95014-2090(316 02 110) SPRIG ELECTRIC CO 1
SAN JOSE,CA 95112 !,
OWNER'S NAME: DATE ISSUED:12/21/2016
OWNER'S PHONE: PHONE NO:(408)298-3134
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#296728 X BLDG X ELECT _PLUMB
Contractor SPRIG ELECTRIC CO Date 04/30/2017
MECH RESIDENTIAL X COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
APPLE-2ND FLOdR;T.I.-BUILDING 6-ADD(3)RECEPTACLES(20
I hereby affirm under penalty of perjury one of the following two declarations: AMP)/3P BREAKER.FOR HVAC(15AMP);
1. I have and will maintain a certificate of consent to self-insure for Worker's RE-FEED(2)(20 AMP)RECEPTACLES;
Compensation,as provided for by Section 3700 of the Labor Code,for the
_� performance of the work for which this permit is issued.
N
z I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this '
permit is issued. _ Sq.Ft Floor Area: Valuation:$15000.00
z it
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 02 110 A(Tenant Improvements)
representatives of this city to enter upon the above mentioned property for
inspection'purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
i Signature_____144-'°:z--------- Date Issued by:Kim Dunbar
Date: 12/21/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS;
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's -
Compensation,as provided for by Section 3700 of the Labor Code,for the '
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Cede,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliaice with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health 4r Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall,•
"„> i
be deemed revoked. Owner or authorized agent:.11---"--
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities, •
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date Professional
\c �/ GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
/4,1-l',J10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228•FAX(408)777-3333•building( ,cupertino.orq el_NI C
CUPERTINO
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❑PLUMBING ❑MECHANICAL A ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 6 1 /" l o( _ Lap vvout APN# 3 [(4, _13 / ....1 (0
OWNER NAME An)' PHONE C.-No,A 9%- Oi o E-MAIL
STREET ADDRESS I I__ ^ Ore
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CONTACT NAME Tocir! 1, i t Lt.) a PHONE lE--M�A`IL
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STREET ADDRESSit \ ` I 11, V CITY,STATE, ZIP eit�y ^ 16 J CA FAX
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❑OWNER 0 OWNER-BUILDER OWNER AGENT 0 CONTRACTOR 0 CONTRACTORAGENT ❑ ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANTJ
CONTRACTOR NAME ri l',,, ,, LICENSE NUMBER LICENSE TYPE BUS.LIC# ifY 3t/I 1
��M I-ki \ACi_no, 253(0 724 &-10 2.lcl14-
COMPANY NAME � FAX
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STREET ADDRESS I R o s. O SI CITY,STATE,ZIPS a n log CA l i z. PHONE S -NS-3131-NA10( i
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
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COMPANY NAME E-MAILFAX
STREET ADDRESS CITY,STATE,ZIP PHONE
'USE OF - ❑SFD or DUPLEX -0 MULTI-FAMILY PROJECTlNWiLDLAND` -- ❑ YES PROJECT IN 0 YES'- :TS-THE-BEOG`AN" -0 YES---'-'--
BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO
DESCRIPTION OF WORK
PdO 13) 20 Alisale, (2,13\1(2,13\1Y/ /// ties
1."V f p f 0( ( �/,�® "1 A
') 8/`r 40, 1 o V 1 l�wM -e!s
�- Ada (SA/ ? btect fOy WA C, neck(?) r-F0 -e-)
.,)inTOTAL VALUATION: ql 1 C. I atRECE / T9/
By my signature below,I certify_ifto each of the following: I am the property owner or authorized agent to act on-the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is adcurate. I agree to comply with all applicable local
a Applicant/Agent: property for inspection purposes.
ordinances and state laws relatingto building construction. I authorize representatives of Cupertino to enter the above-identified
Signature of A licant/A ent: -� Date:
2> OIt (a
1
SUPPLEMENTAL INFORMATION REQUIRED orCE USE ONLv
WCI OVER-TEE-COUNTER
;Grab id. — " a-- `�'"--- t 0 EXPRESS
El STANDARD
: 0 LARGE
Q-MAJOR -
MEPMiscApp_2011.doc revised 06/21/11